Gout

Question 1

Gout

Answer 1

Inflammatory process in response to crystallization of monosodium urate in articular and non-articular tissues

Hyperuricemia: uric acid > 6.8 mg/dL

Question 2

Epidemiology

Answer 2

Men are more likely to be affected by gout

Genetics
Dietary intake
Socioeconomic factors

Question 3

Overproduction

Answer 3

regulatory enzyme variability

cytotoxic medications

increase dietary intake of purines

chronic alcohol intake

Question 4

Underexcretion

Answer 4

Dehydration

Insulin resistance

Acute alcohol intake

Medications

Question 5

Medications that can cause hyperuricemia

Answer 5

Diuretics

Cytotoxic drugs

Salicylates

Question 6

Risk factors

Answer 6

Male
Post-menopausal women
Elderly
Obesity
Diet and alcohol intake
Sedentary lifestyle
Renal impairment

Question 7

Presentation

Answer 7

Acute, inflammatory mono arthritis

Podagra: first metatarsal joint often involved

Uric acid can deposit elsewhere: fingers, wrist, cartilage, kidnets

Question 8

Signs and symptoms

Answer 8

Fever

Intense pain

Erythema, warmth, edema, inflammation of the affected joints

Question 9

Laboratory tests

Answer 9

Uric acid > 6.8 mg/dL
WBC > 11,000 cells/uL

Question 10

Complications

Answer 10

Tophi: deposits of monosodium urate

Nephrolithiasis: kidney stones

Gouty nephropathy

Question 11

General treatment approach

Answer 11

Treatment of pain and inflammation

Use of urate lowering therapy

Anti-inflammatory prophylaxis

Question 12

Non-pharmacologic Therapy for acute attacks

Answer 12

Modify risk factors if able

Applying ice to the affected area

No supplement that shows benefit

Question 13

Acute gouty attacks treatment

Answer 13

NSAID
Corticosteroids
Colchicine

Question 14

NSAID adverse effects

Answer 14

GI bleeding

Kidney injury

CV effects

CNS effects

Question 15

Corticosteroid formulations

Answer 15

Oral: medrol 4 mg dose pack, prednisone 0.5 mg/kg/day, tapered

IM: triamcinolone 60 mg x 1, methylprednisolone 100 mg x 1

Intra-articular: triamcinolone 10-40 mg (large joints), 5-20 (small joints)

If using IM/IA, follow with NSAID or PO corticosteroid

Question 16

Corticosteroid considerations

Answer 16

Taper

Limit duration

Increase risk of GI bleed

Monitor DM

Avoid IA if infection is present

Question 17

Colchicine

Answer 17

Administer within 24 hours of acute attack

Capsule, tablet, solution

DOSE:
Day 1: 1.2 mg PO once, then 0.6 mg one hour later
Day 2+: 0.6 mg BID until attack resolves

Question 18

Colchicine side effects

Answer 18

N/V/D

Question 19

Colchicine renal dose adjustments

Answer 19

CrCl < 30 mL/min

1.2 mg at onset, 0.6 mg 1 hour late (once)

Treatment course should be repeated no more than once every 2 weeks

Question 20

Inadequate initial response

Answer 20

< 50% improvement in pain in 24 hours

Switch agents

Add a 2nd recommended agent: try to avoid NSAIDS with PO corticosteroids

Question 21

Non-pharm for chronic management

Answer 21

Weight loss

DASH diet

Avoid foods high in saturated fats and sweetened beverages/food

Alcohol restriction

Limiting restriction of purine-rich foods

Question 22

Indications for starting ULT

Answer 22

Frequent gout flare > or equal to 2 per year

> or equal to 1 tophus

Radiographic evidence

> 1 prior flare, but infrequent ( < 2 per year)

Patient experiencing first flare in the presence of 1 of the following: CKD stage 3-5, uric acid > 9 mg/dL

Question 23

Who is not a candidate for ULT?

Answer 23

Asymptomatic hyperuricemia with no prior gout flares or tophi

First gout attack without risk factors

Question 24

Xanthine oxidase inhibitors MOA

Answer 24

Reduces uric acid by impairing the ability of xanthine oxidase to convert hypoxanthine to xanthine and therefore uric acid

Question 25

Allopurinol

Answer 25

Initial dose: 100 mg PO daily Titrate every 2-4 weeks in < 100 mg increments as needed to achieve uric acid < 6

Question 26

Febuxostat

Answer 26

Initial dose: 40 mg daily Titrate to 80 mg daily if uric acid > 6 after 2 weeks

Question 27

Allopurinol renal dose adjustments

Answer 27

CrCl < 60: initial dose 50 mg daily Titrate slowly and in small increments, may consider doses > 300 mg with close monitoring

Question 28

Allopurinol adverse reactions

Answer 28

rash HA hives hepatotoxicity hypersensitivity

Question 29

Allopurinol hypersensitivity syndrome

Answer 29

Steven-Jonhson syndrome and toxic epidermal necrolysis Risk factors: Female > 60 yo High initial doses CKD CV disease HLA-B* 5801 allele: Southeast Asian decent

Question 30

Allopurinol monitoring

Answer 30

Uric acid every 2-5 weeks while titrating, every 6 months when stable Renal function, LFTs

Question 31

Allopurinol counseling

Answer 31

Drink plenty of fluids Take this medication even when you do not have gout symptoms

Question 32

Uricosuric Drugs MOA

Answer 32

Increase renal clearance of uric acid by inhibiting post-secretory renal proximal tubular reabsorption of uric acid

Question 33

Probenecid

Answer 33

Initial dose: 250 mg PO BID x 1-2 weeks-->increase to 500 mg BID Titrate by 500 mg increments every 1-2 weeks

Question 34

Probenecid ADRs

Answer 34

Urolithiasis-->CI in patients with history G6PD deficiency Not recommended in eGFR < 60

Question 35

Uricase Agents MOA

Answer 35

Recombinant form of urate-oxidase enzyme that converts uric acid to the more soluble metabolite, allantoin

Question 36

Pegloticase

Answer 36

Used in SEVERE gout and hyperuricemia > 3 gout flare within 18 months > 1 tophi Joint damage due to gout IV infusion: 8 mg every 2 weeks

Question 37

Pegloticase ADRs

Answer 37

BBW: anaphylaxis and infusion reactions, G6PD deficiency-associated hemolysis and methemoglobinemia

Question 38

Pegloticase when to use

Answer 38

Patients who have failed xanthine oxidase inhibitors, uricosurics who continue to have gout flares Patients with non-resolving tophi

Question 39

Gout attack prophylaxis

Answer 39

Use when initiating ULT Goal is to decrease attacks First 3-6 months

Question 40

Agents for prophylaxis

Answer 40

NSAIDS at the lowest effective dose Prednisone < 10 mg/day Colchicine: CrCl < 30--> 0.3 mg daily